Chapter 137. Tinea Capitis

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Chapter 137. Tinea Capitis
Patient Story
An 11yearold boy has a history of 2 months of progressive patchy hair loss (Figure 1371). He has some itching of the scalp but his mother is worried
about his hair loss. Physical examination reveals alopecia with scaling of the scalp and broken hairs looking like black dots in the areas of hair loss. A
KOH preparation is created by scraping an area of alopecia onto a slide. A few loose hairs are added to the slide before the KOH and cover slip are
placed. Fungal elements are seen under the microscope. After 6 weeks of griseofulvin, the tinea capitis is fully resolved.
Figure 1371
Tinea capitis in a young black boy. The most likely organism is Trichophyton tonsurans. (Courtesy of Richard P. Usatine, MD.)
Introduction
Tinea capitis is a fungal infection involving the scalp and hair. It is the most common type of dermatophytoses in children younger than 10 years of age.
Common signs include hair loss, scaling, erythema, and impetigolike plaques.
Synonyms
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Ringworm
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Epidemiology
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Tinea capitis is a fungal infection involving the scalp and hair. It is the most common type of dermatophytoses in children younger than 10 years of age.
Common signs include hair loss, scaling, erythema, and impetigolike plaques.
Synonyms
Ringworm of the scalp and tinea tonsurans.
Epidemiology
Tinea capitis is more common in young, black boys.
Tinea capitis is the most common type of dermatophytoses in children younger than 10 years (Figures 1371, 1372, 1373, 1374, 1375). It
rarely occurs after puberty or in adults.1 The infection has a worldwide distribution.
Combs, brushes, couches, and sheets may harbor the live dermatophyte for a long period of time.
Spread from person to person with direct contact or through fomites.
Occasionally spread from cats and dogs to humans.
Figure 1372
Tinea capitis with patchy hair loss and scaling of the scalp in a young boy. (Courtesy of Richard P. Usatine, MD.)
Figure 1373

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A kerion resulting from inflammation of the tinea capitis on this young boy. The kerion looks superinfected but it is nothing more than an exuberant
inflammatory response to the dermatophyte. (Courtesy of Richard P. Usatine, MD.)
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Tinea capitis with patchy hair loss and scaling of the scalp in a young boy. (Courtesy of Richard P. Usatine, MD.)
Figure 1373
A kerion resulting from inflammation of the tinea capitis on this young boy. The kerion looks superinfected but it is nothing more than an exuberant
inflammatory response to the dermatophyte. (Courtesy of Richard P. Usatine, MD.)
Figure 1374
Closeup of black dot alopecia in a 7yearold girl showing the black dots where infected hairs have broken off. (Courtesy of Richard P. Usatine, MD.)
Figure 1375

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Closeup of black dot alopecia in a 7yearold girl showing the black dots where infected hairs have broken off. (Courtesy of Richard P. Usatine, MD.)
Figure 1375
Lymphadenopathy visible in the neck of this young boy with tinea capitis. The fungal infection shows more scaling and crusting than actual hair loss.
The lymphadenopathy is a reaction to the tinea and not a bacterial superinfection. (Courtesy of Richard P. Usatine, MD.)
Etiology and Pathophysiology

Tinea capitis is a superficial fungal infection affecting hair shafts and follicles on the scalp but could involve the eyebrows and eyelashes.
Caused by Trichophyton and Microsporum dermatophytes. The most common organism in the United States is Trichophyton tonsurans, which is
associated with black dot alopecia. Microsporum canis is less common now than decades ago. M. canis is still highly prevalent in developing
countries. The natural reservoir of M. canis is dogs and cats.
Risk Factors
Lack of access to clean water and soap.
Poverty and living in rural areas.
African descent as the dermatophytes grow well in the follicles of short curly hairs.
Crowded living arrangements in which infected individuals spread the tinea to others.
Sharing combs, brushes, and hair ornaments.
Diagnosis
Chapter
The 137. Tinea
clinical Capitis, is often adequate to make the diagnosis.
appearance Page 4 / 12
Confirm the diagnosis by scraping the scaling areas on the scalp and placing a few loose hairs on a microscope slide with KOH. (DMSO and a
fungal stain will help.) Look for hyphae and spores (Figure 1376). Look for endoectothrix invasion of the hair shaft with fungus.
Poverty and living in rural areas.
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African descent as the dermatophytes grow well in the follicles of short curly hairs.
Crowded living arrangements in which infected individuals spread the tinea to others.
Sharing combs, brushes, and hair ornaments.
Diagnosis
The clinical appearance is often adequate to make the diagnosis.
Confirm the diagnosis by scraping the scaling areas on the scalp and placing a few loose hairs on a microscope slide with KOH. (DMSO and a
fungal stain will help.) Look for hyphae and spores (Figure 1376). Look for endoectothrix invasion of the hair shaft with fungus.
Figure 1376
Tinea capitis with an annular configuration. (Courtesy of Richard P. Usatine, MD.)
Clinical Features
Alopecia and scaling of the scalp (Figures 1371 and 1372).
A kerion occurs when there is an inflammatory response to the tinea. The scalp gets red, swollen, and boggy. There may be serosanguineous
discharge and some crusting as this dries (Figure 1373).
There may be broken hairs that look like black dots in the areas of hair loss (Figure 1374).
Cervical lymphadenopathy is common from the tinea capitis (Figure 1375).
Tinea capitis can even be annular and have the rings of ringworm (Figure 1376).
Typical
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eyebrows and eyelashes.
discharge and some crusting as this dries (Figure 1373).
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There may be broken hairs that look like black dots in the areas of hair loss (Figure 1374).
Cervical lymphadenopathy is common from the tinea capitis (Figure 1375).
Tinea capitis can even be annular and have the rings of ringworm (Figure 1376).
Typical Distribution
By definition it occurs on the head, but usually is found on the scalp. Rarely involves the eyebrows and eyelashes.
Laboratory Studies
Whenever possible it is very important to confirm or dispel ones' clinical suspicion with mycologic evidence before starting weeks of oral antifungal
medicines.
KOH preparation—Scrape the scale and infected hairs using a #15 blade. Then use KOH or a fungal stain to dissolve the keratin. Use the
microscope to look for septate, branching hyphae under 10 and 40 power (Figure 1377). The hyphae of Microsporum may also be found on the
exterior of the hair (exothrix) as in Figure 1378. The hyphae of Trichophyton is found in the interior of the hair (endothrix).
If the diagnosis is uncertain, send a few loose hairs and a scraping of the scalp scale for a fungal culture.
You may look at the scalp with a UV light (Woods lamp), looking for fluorescence, but the yield is low. Only the Microsporum species will fluoresce
(Figure 1379) and this organism is the involved dermatophyte less than 30% of the time.
Figure 1377
T. tonsurans from tinea capitis visible among skin cells at 40 power after adding SwartzLamkins fungal stain. (Courtesy of Richard P. Usatine, MD.)
Figure 1378

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T. tonsurans from tinea capitis visible among skin cells at 40 power after adding SwartzLamkins fungal stain. (Courtesy of Richard P. Usatine, MD.)
Figure 1378
M. canis showing hyphae on the exterior of the hair (exothrix) at 40 power after adding SwartzLamkins fungal stain. (Courtesy of Eric Kraus, MD.)
Figure 1379

A . Tinea capitis in a young boy. B . Fluorescence with an ultraviolet light indicating that this is a Microsporum species causing the tinea capitis.
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A . Tinea capitis in a young boy. B . Fluorescence with an ultraviolet light indicating that this is a Microsporum species causing the tinea capitis.
(Courtesy of Jeff Meffert, MD.)
Differential Diagnosis
Alopecia areata—Produces areas of hair loss with no scaling, inflammation, or scarring in the underlying scalp. It is an autoimmune process in
which the immune system attacks the person's own hair follicles (see Chapter 187, Alopecia Areata).
Seborrhea of the scalp (dandruff)—Is caused by the Pityrosporum yeast, resulting in scaling and inflammation but rarely causing hair loss. The
scalp involvement tends to be more widespread than patchy and localized as seen in tinea capitis (see Chapter 151, Seborrheic Dermatitis).
Scalp psoriasis—Rarely causes alopecia. There are mild cases with slight, fine scaling on the scalp, or severe cases with silvery, thick, crusted
plaques covering the majority of the scalp. Often psoriatic plaques are seen elsewhere on the body and nail changes are visible.
Trichotillomania—Selfinflicted alopecia caused when the patient pulls and twists her/his own hair (see Chapter 188, Traction Alopecia and a
Trichotillomania).
Traction alopecia—Alopecia that occurs when the patient or parent pulls the hair to style it into braids or ponytails. There should be no scaling of
the scalp (unless there is coexisting seborrhea) and the pattern of hair loss should match the hairstyle (Figure 13710) (see Chapter 188, Traction
Alopecia and Trichotillomania).
Scarring alopecia—Seen with systemic lupus erythematosus (SLE) and discoid lupus. Scarring and hypopigmentation should differentiate this
from tinea capitis (see Chapter 189, Scarring Alopecia).
Tinea barbae (Figure 13711) is a type of tinea infection of the hair follicles of the beard.
Figure 13710

Traction alopecia that is related to the tight braids that put pressure on the hair follicle. The slight scaling was caused by seborrhea but tinea capitis
from tinea capitis (see Chapter 189, Scarring Alopecia). Access Provided by:
Tinea barbae (Figure 13711) is a type of tinea infection of the hair follicles of the beard.
Figure 13710
must be in the differential diagnosis. (Courtesy of Richard P. Usatine, MD.)
Figure 13711

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must be in the differential diagnosis. (Courtesy of Richard P. Usatine, MD.)
Figure 13711
Tinea barbae involving the hair follicles of the beard in a 63yearold man with cutaneous lupus. The annular eruption on the neck was initially
confused for his lupus until a potassium hydroxide scraping confirmed a fungal infection. The tinea barbae became inflammatory like a kerion with
swelling of the upper lip before it was cured with oral terbinafine. (Courtesy of Richard P. Usatine, MD.)
Management
Topical antifungal therapy is not adequate and oral treatment is needed.
Griseofulvin remains the treatment of choice for tinea capitis even if it requires a somewhat longer course than the newer antifungal agents.2
5 SOR B Most importantly, it is less expensive and available in a liquid form for children. Prescribe a 6 to 8week course or longer (12week
course) of griseofulvin for tinea capitis.
A 2 to 4week course of terbinafine, fluconazole, and itraconazole are at least as effective as a 6 to 8week course of griseofulvin for the
treatment of Trichophyton infections of the scalp. Griseofulvin is likely to be superior to terbinafine for the rare cases caused by Microsporum
species; its efficacy is matched by itraconazole and fluconazole.5 SOR B
Griseofulvin is available in many forms, including liquid (125 mg microsize/5 cc) for children. Taking the drug with fatty food increases absorption
and 137.
Chapter aids bioavailability.
Tinea Capitis, The dose for microsize griseofulvin is 20 mg/kg per day and ultramicrosize griseofulvin is 10 mg/kg per day. Page 10 / 12
Ultramicrosize
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liquids and can be used for children that can swallow a pill. The standard course should be 6 to 12 weeks for tinea capitis to deal with increasing
resistance patterns.
5 SOR B Most importantly, it is less expensive and available in a liquid form for children. Prescribe a 6 to 8week course or longer (12week
course) of griseofulvin for tinea capitis. Access Provided by:
A 2 to 4week course of terbinafine, fluconazole, and itraconazole are at least as effective as a 6 to 8week course of griseofulvin for the
treatment of Trichophyton infections of the scalp. Griseofulvin is likely to be superior to terbinafine for the rare cases caused by Microsporum
species; its efficacy is matched by itraconazole and fluconazole.5 SOR B
Griseofulvin is available in many forms, including liquid (125 mg microsize/5 cc) for children. Taking the drug with fatty food increases absorption
and aids bioavailability. The dose for microsize griseofulvin is 20 mg/kg per day and ultramicrosize griseofulvin is 10 mg/kg per day.
Ultramicrosize preparations are stronger per mg than the microsize, but do not come in liquid form. The tablets are less expensive than the
liquids and can be used for children that can swallow a pill. The standard course should be 6 to 12 weeks for tinea capitis to deal with increasing
resistance patterns.
Terbinafine is effective and offers a shorter course of therapy than griseofulvin. It is not available in liquid form. Recommended dosage for 10 to
20kg children is 62.5 mg/day; for 20 to 40kg children, 125 mg daily; and for children who weigh more than 40 kg, 250 mg daily. Treatment
duration for Trichophyton is 2 to 4 weeks; it is 8 to 12 weeks for Microsporum infection.
Fluconazole is available in liquid form and appears to be effective and safe to treat cutaneous fungal infections. Recommended dosage is 5 to 6
mg/kg per day. Treatment duration for Trichophyton is 3 to 6 weeks; 8 to 12 weeks for Microsporum infection.
Itraconazole is also available in liquid form. The recommended dose is 3 mg/kg per day for liquid form. For capsules: 5 mg/kg per day. Treatment
duration is 2 to 6 weeks.
None of these agents require laboratory monitoring at the recommended lengths of treatment for tinea capitis.1
A kerion may resolve with oral antifungal treatment alone. If it is severe and painful, consider a short pulse of oral steroids to speed up resolution.
SOR C
Although oral therapy is still the recommended treatment for tinea capitis, topical treatment can be used as adjuvant therapy: 1% or 2.25%
selenium sulfide, 1% ciclopirox, or 2% ketoconazole shampoo should be applied to the scalp and hair for 5 minutes 2 or 3 times a week for 8
weeks.67 SOR B Another use for antifungal shampoo is empirical treatment while waiting for a culture to come back in an equivocal case. SOR C
Prevention
Family members or playmates should be screened and asymptomatic carriers should be treated. Close physical contact and sharing of toys or
combs/hairbrushes should be avoided.8 SOR B
Prognosis
Severe hair loss and scarring alopecia can occur if tinea capitis is left untreated.
Patient Education
Patients and parents need to exercise care to avoid spreading the infection to others. Explain the importance of not sharing combs, brushes, and
towels.
FollowUp
Followup may be scheduled to check for full resolution of the infection by negative culture or hair regrowth.
Patient Resource
Medline Plus article for patients—http://www.nlm.nih.gov/medlineplus/ency/article/000878.htm.
Provider Resource
http://www.emedicine.com/DERM/topic420.htm.
References
1. Johnston KL, Chambliss ML, DeSpain J. Clinical inquiries. What is the best oral antifungal medication for tinea capitis? J Fam Pract. 2001;50:206
207. [PubMed: 11252205]
Chapter
2. Tey HL,137.
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AS, Chan YC. Metaanalysis of randomized, controlled trials comparing griseofulvin and terbinafine in the treatment of tineaPage 11 / 12
capitis. J
Am Acad Dermatol. 2011;64(4):663670. [PubMed: 21334096]
http://www.emedicine.com/DERM/topic420.htm.
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References
1. Johnston KL, Chambliss ML, DeSpain J. Clinical inquiries. What is the best oral antifungal medication for tinea capitis? J Fam Pract. 2001;50:206
207. [PubMed: 11252205]
2. Tey HL, Tan AS, Chan YC. Metaanalysis of randomized, controlled trials comparing griseofulvin and terbinafine in the treatment of tinea capitis. J
Am Acad Dermatol. 2011;64(4):663670. [PubMed: 21334096]
3. Gupta AK, Cooper EA, Bowen JE. Metaanalysis: griseofulvin efficacy in the treatment of tinea capitis. J Drugs Dermatol. 2008;7(4):369372. [PubMed:
18459518]
4. González U, Seaton T, Bergus G, et al. Systemic antifungal therapy for tinea capitis in children. Cochrane Database Syst Rev. 2007 Oct 17;
(4):CD004685.
5. Kakourou T, Uksal U; European Society for Pediatric Dermatology. Guidelines for the management of tinea capitis in children. Pediatr Dermatol.
2010;27(3):226228. [PubMed: 20609140]
6. Greer DL. Successful treatment of tinea capitis with 2% ketoconazole shampoo. Int J Dermatol. 2000;39(4):302304. [PubMed: 10809984]
7. Chen C, Koch LH, Dice JE, et al. A randomized, doubleblind study comparing the efficacy of selenium sulfide shampoo 1% and ciclopirox shampoo
1% as adjunctive treatments for tinea capitis in children. Pediatr Dermatol. 2010;27(5):459462. [PubMed: 20735804]
8. Higgins EM, Fuller LC, Smith CH. Guidelines for the management of tinea capitis. British Association of Dermatologists. Br J Dermatol.
2000;143(1):5358. [PubMed: 10886135]


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